DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY
RESIDENTIAL BASEMENT FLOODPROOFING CERTIFICATE
See Reverse Side for Paperwork Burden Disclosure Statement
O.M.B. No. 1660-0033 Expires June 30, 2010
For use ONLY in communities which have been granted an exception by FEMA to allow the construction of floodproofed residential basements in Special Flood Hazard Areas.
BUILDING OWNER'S NAME FOR INSURANCE COMPANY USE POLICY NUMBER COMPANY NAIC NUMBER
BUILDING STREET ADDRESS (Including Apt., Unit Number) OTHER DESCRIPTION (Lot and Block Numbers, etc.)
CITY
STATE
ZIP CODE
SECTION I - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION Provide the following from the FIRM and flood profile (from Flood Insurance Study)
COMMUNITY NUMBER PANEL NUMBER SUFFIX DATE OF FIRM ZONE BASE FLOOD ELEVATION NAME OF FLOODING SOURCE(S) (NGVD) (In AO Zones, Use depth) AFFECTING BUILDING
SECTION II - FLOODPROOFING INFORMATION (By a Registered Professional Engineer or Architect)
Floodproofing Design Elevation Information: Building is floodproofed to an elevation of (Elevation datum used must be the same as that on the FIRM) Elevation of the top of the basement floor is . feet in NGV.
.
feet in NGV.
(NOTE: The floodproofing design elevation must be at least one foot avove the Base Flood Elevation (BFE)
SECTION III - CERTIFICATION (By a Registered Professional Engineer or Architect)
Residential Floodproofed Basement Construction Certification:
I certify that based upon development and/or review of structural design specifications, and plans for construction, including consideration of the depth, velocity, and duration of flooding and the type and permeability of soils at the site, that the design and methods of construction of the floodproofed basement to be used are in accordance with accepted standards of practice for meeting the following provisions: * Basement area, together with attendant utilities and sanitary facilities, is watertight to the floodproofing design elevation with walls that are impermeable to the passage of water without human intervention; and * Basement walls and floor are capable of resisting hydrostatic and hydrodynamic loads and the effects of buoyancy resulting from flooding to the floodproofing design elevation; and have been designed so that minimal damage will occur from floods that exceed the floodproofing design elevation; and * Building design, including the floodproofing design elevation, complies with community requirements.
I certify that the information on this certificate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S.CODE 1001.
CERTIFIER'S NAME TITLE ADDRESS SIGNATURE COMPANY NAME CITY STATE PHONE NO. ZIP DATE LICENSE NUMBER (or affix Seal)
Copies of this certificate must be given to: 1) the community official: 2) the insurance agent: and 3) the building owner.
FEMA Form 81-78, JUL O7 PREVIOUS EDITIONS ARE OBSOLETE.
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 3.25 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this Residential Basement Floodproofing Certificate. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this Residential Basement Floodproofing Certificate. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0033) NOTE: Do not send your completed form to this address.